Surgical clip applicator and apparatus including the same

ABSTRACT

Apparatus and methods for delivering a surgical clip to a patient during a minimally invasive surgical procedure.

BACKGROUND OF THE INVENTIONS

1. Field of Inventions

The present inventions relate generally to devices for delivering and installing surgical clips.

2. Description of the Related Art

There are many instances where surgical clips are secured to tissue within a patient. One example of such a procedure is the treatment of atrial fibrillation. Atrial fibrillation occurs when anatomical obstacles in the heart disrupt the normally uniform propagation of electrical impulses in the atria. These anatomical obstacles (called “conduction blocks”) can cause the electrical impulse to degenerate into several circular wavelets that circulate about the obstacles. The wavelets (called “reentry circuits”) disrupt the normally uniform activation of the left and right atria. Because of a loss of atrioventricular synchrony, the people who suffer from atrial fibrillation also suffer the consequences of impaired hemodynamics and loss of cardiac efficiency. They are also at much greater risk of strokes and other thromboembolic complications because of loss of effective contraction and atrial stasis. With respect to strokes, thrombus can form in left atrial appendage, break off, and cause a stroke. The risk of stroke for people with atrial fibrillation is about five (5) times that of those who do not have atrial fibrillation.

Electrosurgical devices have been used in minimally invasive procedures to form a set of three transmural epicardial encircling lesions that cures paroxysmal atrial fibrillation in most patients. The epicardial lesion set that typically cures paroxysmal atrial fibrillation includes an encircling lesion around the right pulmonary vein pair, an encircling lesion around the left pulmonary vein pair and an encircling lesion around the left atrial appendage. Additional epicardial lesions are frequently required for patients with persistent or permanent atrial fibrillation. A transmural “connecting” lesion that connects the lesion around the right pulmonary vein pair to the lesion around the left pulmonary vein pair may be required if these lesions do not overlap, and a transmural connecting lesion that connects the lesion around the left pulmonary vein pair to the lesion around the left atrial appendage may be required if these lesions do not overlap. Electrosurgical clamps may be used to form the epicardial encircling lesions and electrosurgical probes may be used to form the epicardial connecting lesions. Exemplary electrosurgical clamps and surgical probes are disclosed in U.S. Pat. Nos. 6,142,994 6,610,055 and U.S. Patent Pub. Nos. 2003/0158547 A1 and 2005/0119654 A1. In minimally invasive procedures, access to the heart is typically obtained via a thoracotomy and a relatively small (e.g. about 10 mm in diameter) access port.

There is, unfortunately, some likelihood that a patient's atrial fibrillation will not be cured by the above-described minimally invasive epicardial procedure and such a patient will also continue suffer from the associated increase in the risk of stroke. In context of more invasive atrial fibrillation treatments, such as open heart surgical maze procedures, one method of reducing subsequent stroke risk in patients is to isolate the interior of the atrial appendage from the left atria. This eliminates the possibility of thrombus within the atrial appendage entering the blood stream. The isolation may be accomplished by suturing the base of the atrial appendage closed, or by applying a clip by hand to epicardial surface at the base of the atrial appendage.

The present inventor has determined that although the use of a clip is a convenient way to isolate an atrial appendage, a need exist for a device that is capable of delivering a clip to a target tissue structure during minimally invasive surgical procedures, where application by hand is not possible.

SUMMARY OF SOME OF THE INVENTIONS

An apparatus in accordance with an invention herein includes a mounting portion configured to be removably secured to a clamp and an engagement portion configured to releasably engage at least a portion of a surgical clip. Another apparatus in accordance with an invention herein includes a clamp and a clip applicator, associated with the clamp, including an engagement portion configured to releasably engage at least a portion of a surgical clip. Still another apparatus in accordance with an invention herein is a unitary structure configured to be removably secured to a clamp and to releasably engage at least a portion of a surgical clip.

Such apparatus provide a number of advantages. For example, the present apparatus may be used to deliver a surgical clip to a target tissue structure during minimally invasive surgical procedures. More specifically, after a surgical clip is removably secured to a clamp, the clamp may be moved to a closed (or substantially closed) orientation so that the clip and clamp can be inserted into a patient through a relatively small access port. The clamp may then be used to positing the surgical clip on the target tissue structure. Once the surgical clip is in place, the clamp may be separated from the clip and removed from the patient.

The above described and many other features and attendant advantages of the present inventions will become apparent as the inventions become better understood by reference to the following detailed description when considered in conjunction with the accompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

Detailed description of embodiments of the inventions will be made with reference to the accompanying drawings.

FIG. 1 is a perspective view of one example of a conventional clip that may be used in combination with a present invention.

FIG. 2 is a perspective view of a clip application apparatus in accordance with one embodiment of a present invention.

FIG. 3 is a perspective view of a clamp.

FIG. 4 is a plan view of a portion of the clamp illustrated in FIG. 3.

FIG. 5 is a section view taken along line 5-5 in FIG. 4.

FIG. 6 is a plan view of a portion of a clip applicator in accordance with one embodiment of a present invention.

FIG. 7 is a side view of the clip applicator illustrated in FIG. 6.

FIG. 8 is a section view taken along line 8-8 in FIG. 7.

FIG. 9 is a section view taken along line 9-9 in FIG. 7.

FIG. 10 is a section view taken along line 10-10 in FIG. 7.

FIG. 11 is a side view showing a clip prior to being secured to a clip application apparatus in accordance with one embodiment of a present invention.

FIG. 12 is a section view taken along line 12-12 in FIG. 11.

FIG. 13 is a side view showing the clip being secured to the clip application apparatus in illustrated in FIG. 11.

FIG. 14 is a section view taken along line 14-14 in FIG. 13.

FIG. 15 is a side view showing the clip secured to the clip application apparatus in illustrated in FIG. 10.

FIG. 16 is a section view taken along line 16-16 in FIG. 15.

FIG. 17 is a side view showing the clip application apparatus illustrated in FIG. 11 compressing the clip.

FIG. 18 is a side, section view showing the clip application apparatus illustrated in FIG. 11 locking the clip on a tissue structure.

FIG. 19 is a section view showing the clip on a tissue structure after the clip application apparatus has been withdrawn.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

The following is a detailed description of the best presently known modes of carrying out the inventions. This description is not to be taken in a limiting sense, but is made merely for the purpose of illustrating the general principles of the inventions.

Although the present inventions are not limited to use with any particular surgical clips, one example of a conventional surgical clip that may be inserted into a patient and secured to a tissue structure is illustrated in FIG. 1. The exemplary surgical clip 100 is a unitary structure that includes a top portion 102 and a bottom portion 104 that pivot relative to one another about a pre-bent hinge 106 that is biased to the open orientation illustrated in FIG. 1. The surgical clip 100 also includes a locking apparatus 108 and a plurality of tissue engagement devices 110. Once the surgical clip 100 is locked in place, the tissue engagement devices 110 will prevent the surgical clip from moving by pressing into the tissue. Scar tissue will also form around the tissue engagement devices 110, which further prevents movement. In the illustrated embodiment, the locking apparatus 108 includes a first locking member 112 with a pair of inwardly extending cam surfaces 114 and a second locking member 116 with a pair of deflectable latches 118. A cutout 120 in the top portion 102 of the surgical clip 100 allows the latches 118 to move relative to one another.

The exemplary surgical clip 100 illustrated in FIG. 1 may be secured to a tissue structure, either by hand during invasive surgical procedures or through the use the present surgical clip application apparatus 10 illustrated in FIG. 2 during minimally invasive procedures, as follows. After the surgical clip 100 is positioned about the target tissue structure, force is applied to the top and bottom portions 102 and 104 and, as the top and bottom portions approach the locked orientation (FIG. 19), the latches 118 engage the cam surfaces 114 and move toward one another. The latches 118 continue to move toward one another until they pass the cam surfaces 114, at which time they spring apart. The surgical clip 100 is then released and the biasing force of the hinge 106 forces the now spread apart latches 118 against the underside of the cam surfaces 114, thereby preventing the surgical clip 100 from returning to the open position. The surgical clip 100 may also be unlocked, if necessary, by pushing the latches 118 toward one another so that the biasing force of the hinge 106 can force the latches 118 through the cam surfaces 116.

The exemplary surgical clip application apparatus 10 illustrated in FIG. 2 includes a clamp 200 and a surgical clip applicator 300 carried by the clamp. As used herein, the term “clamp” includes, but is not limited to, clamps, forceps, hemostats, and any other surgical device that includes a pair of opposable clamp members, at least one of which is movable relative to the other. In some instances, the clamp members are connected to a scissors-like arrangement including a pair of handle supporting arms that are pivotably connected to one another. The clamp members are secured to one end of the arms and the handles are secured to the other end. Certain clamps that are particularly useful in minimally invasive procedures also include a pair of handles and a pair of clamp members. Here, however, the clamp members and handles are not mounted on the opposite ends of the same arm. Instead, the handles are carried by one end of an elongate housing and the clamp members are carried by the other. A suitable mechanical linkage located within the housing causes the clamp members to move relative to one another in response to movement of the handles. The clamp members may be linear or have a predefined curvature that is optimized for a particular surgical procedure or portion thereof. The clamp members may also be rigid or malleable.

One example of a clamp is generally represented by reference numeral 200 in FIGS. 2-5. Referring more specifically to FIGS. 3-5, the clamp 200 includes a pair of rigid arms 202 and 204 that are pivotably connected to one another by a pin (not shown). The proximal ends of the arms 202 and 204 are respectively connected to a pair handle members 206 and 208, while the distal ends are respectively connected to a pair of clamp members 210 and 212. The clamp members 210 and 212 may be rigid or malleable and, if rigid, may be linear or have a pre-shaped bend (as shown). A locking device 214 locks the clamp in the closed orientation, and prevents the clamp members 210 and 212 from coming any closer to one another than is illustrated in FIG. 3. The clamp 200 is also configured for use with a pair of soft, deformable inserts (not shown) that may be removably carried by the clamp members 210 and 212 and allow the clamp to firmly grip a bodily structure without damaging the structure. To that end, the clamp members 210 and 212 each include a slot 216 (FIGS. 4 and 5) that is provided with a sloped inlet area 218 and the inserts include mating structures that are removably friction fit within the slots. The present surgical clip applicators may be mounted on one of the clamp members in place of the insert and, typically, there will be no insert on the other clamp member.

Turning to FIGS. 6-10, the exemplary surgical clip applicator 300 includes a mounting portion 302, which secures the surgical clip applicator to the clamp 200, and an engagement portion 304, which releasably engages the surgical clip 100. The mounting portion 302 includes a base member 306 and a connector 308 that is configured to removably mate with the clamp slot 216 (FIGS. 4 and 5). The exemplary connector 308 has a relatively thin portion 310 and a relatively wide portion 312, which may consist of a plurality of spaced members (as shown) or an elongate unitary structure, in order to correspond to the shape of the slot 216. The mounting portion may be modified so that surgical clip applicators in accordance with the present inventions may be used in conjunction with clamps that do not include a clamp member slot. Here, the connector 308 may be eliminated and the base member reconfigured such that it includes a longitudinally extending aperture into which a clamp member may be inserted. The aperture and base member should be sized and shaped such that the base member will be forced to stretch when the clamp member is inserted in order to create a tight interference fit between the base member and clamp member.

The engagement portion 304 includes a bottom surface 314, flexible flaps 316 and an end stop 318. The exemplary flaps 316, which extend longitudinally, have an inverted L-shape and together define a slot 320, are positioned along the sides of the bottom surface 314 and are used to releasably engage the surgical clip. The flaps 316 have a fixed end 317 (FIG. 9), which is connected to the bottom surface 314, and a free end 319. Although the present inventions are not limited to use with any particular surgical clip, the exemplary surgical clip applicator 300 is configured for use with the surgical clip 100 illustrated in FIG. 1. To that end, the distal end of the surgical clip applicator 300 includes an open region 322 (i.e. a region without one or more of the flexible flaps 316) for the first locking member 112, an open region 324 for the tissue engagement device 110 on the clip bottom portion 104, and an open region 326 for the hinge 106.

One method of securing the exemplary surgical clip 100 to the exemplary surgical clip applicator 300 on the surgical clip application apparatus 10 is illustrated in FIGS. 11-16. Referring first to FIGS. 11 and 12, the surgical clip 100 is placed on the engagement portion bottom surface 314 at the open region 324 while the surgical clip applicator 300 is in a relaxed state. The surgical clip 100, which is oriented such that the hinge 106 faces proximally, is then moved in the direction indicated by arrow A (i.e. along the longitudinal axis of the surgical clip applicator 300). The surgical clip 100 causes the flexible clip applicator flaps 316 to deflect in the manner illustrated in FIGS. 13 and 14 as the surgical clip moves through the slot 320 in the direction indicated by arrow A. More specifically, the portions of the flaps 316 that are adjacent to the clip hinge 106 will deflect when aligned with the clip hinge and will return to the unstressed state after the clip hinge moves past them. The movement in the direction indicated by arrow A, and corresponding deflection of the portions of the flaps 316 that are adjacent to the clip hinge 106, will continue until the surgical clip 100 reaches the stored position illustrated in FIGS. 15 and 16. The end stop 318 may, if necessary, be used to prevent the surgical clip 100 from moving too far in the proximal direction. In the stored position, the clip bottom portion 104 is held within the slot 320, the first locking member 112 is aligned with the open region 322, the tissue engagement device 110 on the clip bottom portion 104 is aligned with the open region 324, and the hinge 106 is aligned with the open region 326. The surgical clip 100 is, at this point, “releasably engaged” to the clamp member 210, i.e. the surgical clip is secured to the clamp member 210 in such a manner that the surgical clip will remain secured to the clamp member 210 without assistance from (and in the absence of contact with) the clamp member 212, yet can also be readily disengaged from the clamp member 210.

It should be noted that the exemplary surgical clip application apparatus 10 includes a single surgical clip applicator 300. As such, the clip top portion 102 is not directly secured to the surgical clip application apparatus 10. There may, however, be some instances where a pair of surgical clip applicators 300 are used to secure a surgical clip to both of the clamp members 210 and 212 in the surgical clip application apparatus 10.

Once the surgical clip 100 is in the stored position, and is removably secured to the surgical clip applicator 300, as well as to the clamp 200 by way of the surgical clip applicator, the surgical clip may be inserted into the patient with the surgical clip application apparatus 10. As illustrated for example in FIG. 17, the clamp members 210 and 212 may be brought into close proximity to one another, although not so close that they cause the clip locking members 112 and 116 on the surgical clip 100 to engage one another, so that the distal portion of the surgical clip application apparatus 10 can be inserted with the surgical clip into a patient by way of a thoracotomy and/or a relatively small access port (e.g. about 10 mm). Once inside the patient, the clamp members 210 and 212 may be moved apart so that the surgical clip 100 will return to its open state (or partially opened state) and be positioned around the target tissue structure, e.g. around the epicardial base of the left atrial appendage LAA. Next, as illustrated in FIG. 18, the clamp members 210 and 212 may be used to compress the surgical clip 100 around the base of left atrial appendage LAA until the locking members 112 and 116 lock the surgical clip in place. The surgical clip application apparatus 10 may then be opened and moved proximally, while the surgical clip 100 remains secured to the left atrial appendage LAA, which cause the flexible clip applicator flaps 316 to deflect and release the surgical clip.

With respect to materials and dimensions, and although the present surgical clip applicators are not limited to any particular materials and dimensions, surgical clip applicators in accordance with the present inventions may be formed from any suitable flexible biocompatible material. Exemplary materials include polyurethane silicone, polyurethane/silicone blends and Pebax blends with a Shore hardness of about 30D to 55D. Preferably, the flaps 316 will be extremely flexible, i.e. just rigid enough to prevent the surgical clip 100 from falling off of the surgical clip applicator 300, in order to facilitate separation of the surgical clip and surgical clip application apparatus 10 after the surgical clip has been locked onto the target tissue structure. The size of the surgical clip applicator 300 will, of course depend upon the size of the surgical clip that it is intended to hold. In the illustrated embodiment, the surgical clip applicator is about 40 mm to 55 mm long and about 7 mm to 10 mm wide at its widest point. The flaps 316 are about 1 mm to 3 mm high (measured from the bottom surface 314) and extend inwardly from the outer edge about 0.5 mm to 1.5 mm. The slot 320 is about 6 mm to 7 mm wide and about 0.5 mm to 1.5 mm high (measured from the bottom surface 314 to the underside of the flap 316) at its widest point, and about 4 mm to 5 mm wide and about 2 mm to 3 mm high (measured from the bottom surface 314 to the top of the flap 316) at its narrowest point.

Turning to manufacture, and although the present surgical clip applicators are not limited to any particular manufacturing processes, surgical clip applicators in accordance with the present inventions may be formed as unitary structures (i.e. one piece structures) with a molding process such as injection molding or casting. Alternatively, the surgical clip applicators may be formed from multiple parts that are individually molded or machined and then secured to one another.

In other exemplary surgical clip application apparatus, the clamp and surgical clip applicator described above may be combined into an integral unit that cannot be readily separated. For example, the surgical clip applicator may be molded onto a clamp member. Such a surgical clip applicator would, for example, extend completely around the clamp member and/or include portions that are molded into the clamp member slots.

Although the inventions disclosed herein have been described in terms of the preferred embodiments above, numerous modifications and/or additions to the above-described preferred embodiments would be readily apparent to one skilled in the art. By way of example, but not limitation, the flexible flaps may, instead of being L-shaped, be curved or planar. Planar flexible flap would be oriented at an acute angle with respect to the bottom surface 314. Single flap configurations are also possible. It is intended that the scope of the present inventions extend to all such modifications and/or additions and that the scope of the present inventions is limited solely by the claims set forth below. 

1. An apparatus, comprising: a mounting portion configured to be removably secured to a clamp; and an engagement portion configured to releasably engage at least a portion of a surgical clip.
 2. An apparatus as claimed in claim 1, wherein the mounting portion includes a longitudinally extending connector with a relatively wide portion and a relatively narrow portion.
 3. An apparatus as claimed in claim 1, wherein the engagement portion includes at least one flexible flap.
 4. An apparatus as claimed in claim 3, wherein the at least one flexible flap comprises at least one longitudinally extending flexible flap.
 5. An apparatus as claimed in claim 1, wherein the engagement portion includes first and second flexible flaps that define a slot therebetween.
 6. An apparatus as claimed in claim 5, wherein the engagement portion includes a bottom surface, the flexible flaps each include a fixed end associated with the bottom surface and a free end, and the free ends of the flexible flaps are spaced from one another.
 7. An apparatus as claimed in claim 5, wherein the first and second flexible flaps comprise first and second longitudinally extending flexible flaps.
 8. An apparatus as claimed in claim 1, wherein the engagement portion defines a longitudinal axis and is configured to receive the surgical clip as the surgical clip moves along the longitudinal axis.
 9. An apparatus for use with a clamp including first and second clamp members, the apparatus comprising: a mounting portion configured to be removably secured to the first clamp member; and engagement means for releasably engaging a surgical clip such that the surgical clip is secured to the first clamp member.
 10. An apparatus as claimed in claim 9, wherein the mounting portion includes a longitudinally extending connector with a relatively wide portion and a relatively narrow portion.
 11. A surgical clip application apparatus, comprising: a clamp including a first clamp member, a second clamp member, and movement apparatus that moves at least one of the first and second clamp members relative to the other of the first and second clamp members; and a clip applicator, associated with the first clamp member, including an engagement portion configured to releasably engage at least a portion of a surgical clip.
 12. An apparatus as claimed in claim 11, wherein the movement apparatus comprises first and second arms pivotably secured to one another.
 13. An apparatus as claimed in claim 11, wherein the clip applicator is removably secured to the first clamp member.
 14. An apparatus as claimed in claim 13, wherein the first clamp member includes a slot; and the clip applicator includes a connector configured to mate with the slot.
 15. An apparatus as claimed in claim 11, wherein the engagement portion includes at least one flexible flap.
 16. An apparatus as claimed in claim 15, wherein the at least one flexible flap comprises at least one longitudinally extending flexible flap.
 17. An apparatus as claimed in claim 11, wherein the engagement portion includes first and second flexible flaps that define a slot therebetween.
 18. An apparatus as claimed in claim 17, wherein the engagement portion includes a bottom surface, the flexible flaps each include a fixed end associated with the bottom surface and a free end, and the free ends of the flexible flaps are spaced from one another.
 19. An apparatus as claimed in claim 17, wherein the first and second flexible flaps comprise first and second longitudinally extending flexible flaps.
 20. An apparatus as claimed in claim 11, wherein the engagement portion defines a longitudinal axis and is configured to receive the surgical clip as the surgical clip moves along the longitudinal axis.
 21. A method of deploying a surgical clip with a clamp including first and second clamp members, the method comprising the steps of: releasably securing a surgical clip to the first clamp member; compressing the surgical clip with the clamp; inserting the surgical clip into a patient in a minimally invasive manner; securing the surgical clip to a target tissue structure with the clamp; and separating the first clamp member from the surgical clip.
 22. An apparatus as claimed in claim 21, wherein the step of releasably securing comprises sliding the surgical clip onto a clip applicator that is carried by the first clamp member such that the clip applicator releasably engages the surgical clamp.
 23. An apparatus as claimed in claim 21, wherein the step of inserting the surgical clip comprises inserting the surgical clip into the patient's chest through an access port.
 24. An apparatus as claimed in claim 21, wherein the step of securing the surgical clip comprises securing the surgical clip to an epicardial surface of an atrial appendage.
 25. An apparatus, comprising: a unitary structure configured to be removably secured to a clamp and to releasably engage at least a portion of a surgical clip.
 26. An apparatus as claimed in claim 25, wherein the unitary structure includes a longitudinally extending connector with a relatively wide portion and a relatively narrow portion.
 27. An apparatus as claimed in claim 25, wherein the unitary structure includes at least one flexible flap.
 28. An apparatus as claimed in claim 27, wherein the at least one flexible flap comprises at least one longitudinally extending flexible flap.
 29. An apparatus as claimed in claim 25, wherein the unitary structure includes first and second flexible flaps that define a slot therebetween.
 30. An apparatus as claimed in claim 29, wherein the flexible flaps each include a fixed end and a free end, and the free ends of the flexible flaps are spaced from one another.
 31. An apparatus as claimed in claim 29, wherein the first and second flexible flaps comprise first and second longitudinally extending flexible flaps.
 32. An apparatus as claimed in claim 25, wherein the unitary structure defines a longitudinal axis and is configured to receive the surgical clip as the surgical clip moves along the longitudinal axis. 